Varicocele

Background

• Definition of a varicocele: abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus

Epidemiology

• Found in ≈15% of the general population, 35% of men with primary infertility, and 75-81% of men with secondary infertility
  • Prevalence of clinically diagnosed varicoceles in adolescents (8-16%) similar to prevalence in adults (15%)
  • Adolescent varicocele may contribute significantly to the risk of subfertility in adulthood

Pathogenesis

• The primary factors are believed to be:
  1. Increased venous pressure in the left renal vein
  2. Valvular incompetence of the gonadal vein at its junction with the left renal vein
  3. Collateral venous anastomoses
• The “nutcracker phenomenon” (compression of the left renal vein between the aorta and superior mesenteric artery) may account for the varicocele in some boys
• A tall, thin body habitus (low BMI) is associated with varicoceles in adolescents and adults
• Solitary right varicoceles are rare. Should one be of abrupt onset, renal pathology such as tumour should be considered

Grading

• Grade 0 (subclinical): non-palpable and visualized only by colour-doppler US
• Grade 1: palpable only with Valsalva maneuver but not visible on physical exam
• Grade 2: easily palpable but not visible on physical exam
• Grade 3: easily visible on physical exam

Associated Pathologic Processes

• Can impair testicular growth and fertilty with a progressive and duration-dependent decline by interrupting counter-current heat exchange provided by pampinoform plexus, resulting in increased testicular temperature
  1. Testicular growth
     • “Catch-up” growth, defined as normalization of left relative to right testicular size, occurs in 32-83% of patients after varicocele repair
     • Significant discrepancy between left and right testicular size remains the primary indication for varicocele correction
  2. Fertility
     • Reliable standards for semen quality based on Tanner stage or age do not exist
     • Trends toward poorer sperm quality may be limited to a subset of affected males with varicocele
       • Varicocle grade and postoperative testicular catch-up growth do not reliably predict ultimate semen quality
  3. Hormonal Function
     • LH and FSH levels are not consistently different in the presence or absence of varicocele in adolescents

Diagnosis and Evaluation

• Vast majority of varicoceles in children and adolescents are identified incidentally
• 85% are left unilateral due to asymmetric gonadal vein anatomy, 15% may be either bilateral (more common) or right unilateral (less common)§

History and Physical Exam

• Physical Exam
  • Examine the patient in both the supine and standing positions. The veins should decompress in the supine position
    • Failure to do so, particularly on the right side, may be from an abdominal or pelvic mass.
    • 2020 AUA Guidelines on Infertility:
  • Testicular consistency should be assessed; the affected testis may be soft.
  • Measurement of testicular volume is important because it may predicate surgical intervention

Imaging

• Abdominal/pelvic CT or US
  • Routine imaging based solely on the presence of a right varicocele is unnecessary.★
  • Abdominal imaging should be considered for men with a new onset or non-reducible varicocele, especially if varicocele is large★

Management

Options

1. Observation
2. Varicocelectomy

Observation

• Remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present

Varicocelectomy

Indications (4):

1. Significant (≥20%) size discrepancy
2. Bilateral testicular hypotrophy
3. Abnormal semen analysis findings; most reliable in boys of Tanner stage 5 and/or at least 18 years of age
4. Pain; a rare indication

Potential benefits

• Halt the progressive duration-dependent decline in semen quality found in men with varicoceles.
  • Repair of large varicoceles results in a significantly greater improvement in semen quality than repair of small varicoceles
    • Microsurgical varicocelectomy results in return of sperm to the ejaculate in up to 50% of azoospermic men with palpable varicoceles
  • A randomized controlled trial of surgery versus no surgery in infertile men with varicoceles revealed a pregnancy rate of 44% at 1 year in the surgery group versus 10% in the control group.
  • See Risk Calculator for Predicting Changes in Semen Parameters in Infertile Men After Varicocele Repair
• Improve Leydig cell function, resulting in increased testosterone levels
  • In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone results in substantial improvement in serum testosterone levels

Anatomical considerations

• The pampiniform plexus of veins forms from the gonadal/internal spermatic veins.
  • These veins are ligated during varicocele ligation surgery.

• Deferential veins follow the vas deferens and empty into the internal iliac/hypogastric veins.
  • These veins are spared during varicocele ligation surgery.

Approaches (5)

1. Radiographic
2. Retroperitoneal
3. Laparoscopic
4. Conventional inguinal
5. Microsurgical Inguinal and Subinguinal

Radiographic

• Venographic placement of agents (3% sodium tetradecyl sulfate or polidocanol, with or without intravascular coils or balloons)
• Can be done in either a retrograde or antegrade fashion
• Advantages:
  1. Identify and classify the venous collateralization as possible routes of outflow and reflux
  2. Minimally invasive approach through a transfemoral venous puncture done under local anesthesia (with or without sedation)
• Disadvantages
  1. High incidence of varicocele recurrence
  2. Radiation exposure
  3. Short follow-up in available literature

Retroperitoneal

• Involves incision at the level of the internal inguinal ring, splitting of the external and internal oblique muscles, and exposure of the gonadal/internal spermatic artery and vein retroperitoneally near the ureter.
• Still a commonly used method for the repair of varicocele, especially in children.
• Advantages:
  • Involves ligation of the fewest number of veins
    • This approach isolates the gonadal/internal spermatic veins proximally, near the point of drainage into the left renal vein. At this level, only 1-2 large veins are present, and in addition the testicular artery has not yet branched and is often distinctly separate from the internal spermatic veins.
      • Despite the above statement, CW11 Table 25-5 suggests that the artery is not preserved with retroperitoneal approach
• Disadvantages:
  • High incidence of varicocele recurrence and hydrocele formation

Laparoscopic

• In essence a retroperitoneal approach
• Similar advantages and disadvantages to those of the open retroperitoneal approach
  • High incidence of hydrocele formation

Conventional inguinal

• Disadvantages:
  • High incidence of hydrocele formation
  • Artery not preserved
• If an inguinal approach is selected, the external oblique aponeurosis is cleaned and opened the length of the incision to the external inguinal ring in the direction of its fibers. A 3-0 absorbable suture placed at the apex of the external oblique incision facilitates later closure. The spermatic cord is grasped with a Babcock clamp and delivered through the wound. The ilioinguinal and genital branches of the genitofemoral nerve are carefully excluded from the cord, which is then surrounded with a large Penrose drain

Microsurgical Inguinal and Subinguinal

• Advantages
  1. Facilitates artery and lymphatic sparing
  2. Low rate of varicocele recurrence
  3. Low risk of hydrocele
• Disadvantages:
  1. May be time-consuming
  2. Requires microscopic surgical skills
• Indications for inguinal vs. subinguinal varicocelectomy (see CW11 Table 25-6)
  • Subinguinal approach
    • Currently the most popular approach
    • Preferred in men with a history of any prior inguinal surgery
    • Significantly more difficult than a high inguinal operation and should be used only by surgeons who perform the operation frequently
    • Associated in rare cases with testicular atrophy (necrosis), which has not been reported for suprainguinal procedures
  • Inguinal approach
    • Used when simultaneous ipsilateral hernia repair is performed
• An inguinal or subinguinal approach allows access to cremesteric/external spermatic vein and even gubernacular veins
• At the completion of the microsurgical varicocelectomy, only the testicular arteries, cremasteric arteries, lymphatics, and vas deferens with its vessels remain (i.e. deferential artery and vein are intact)
  • As long as at least one set of deferential veins remains intact, venous return will be adequate

Scrotal

• Avoided because damage to the arterial supply of the testis frequently results in testicular atrophy and further impairment of spermatogenesis and fertility

Complications

1. Failure (varicocele persistence or recurrence)
2. Hydrocele formation after varicocelectomy is caused by lymphatic obstruction
3. Injury or ligation of the testicular artery carries with it the risk of testicular atrophy and/or impaired spermatogenesis
   • See Table 25-5 for techniques and complications of varicocelectomy
     • UrologySchool.com Summary of Table
       • High rates of varicocle recurrence: retroperitoneal and radiographic
       • High rates of hydrocele: retroperitoneal, laparoscopic, and conventional inguinal
       • Artery not preserved: retroperitoneal and conventional inguinal

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 25
• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 146